2. The policy has now been encapsulated in legislation in chapter 5 of the National Health Act, 2003 (Act 61 of 2003) (The Act).

3. During the development of the policy over the past 10 years different options were put forward on how best to achieve the common objectives, and this has left some confusion.

4. The aims of this document are:

a. To give a clear vision of the District Health System

b. To discuss some critical implications of the National Health Act

c. To clarify actions that must be taken now:

i To implement the Act

ii. To identity other areas that still require policy decisions, and

iii. To identify the policy options in those areas

B: VISION FOR THE DHS IN EACH HEALTH DISTRICT

a. In 1986 the World Health Organization defined a District Health System as follows, as quoted in the 1994 National Health Plan and the1995 Policy document: A District Health System based on Primary Health Care is a more or less self-contained segment of the National Health System. It comprises first and foremost a well-defined population, living within a clearly delineated administrative and geographical area, whether urban or rural. It includes all institutions and individuals providing health care in the district, whether governmental, social security, non-governmental, private, or traditional. A District Health System therefore consists of a large variety of interrelated elements that contribute to health in homes, schools, work places, and communities, through the health and other related sectors. It includes self care and all health care workers and facilities, up to and including the hospital at the first referral level, and the appropriate laboratory, other diagnostic, and logistic support services.

b. The 12 guiding principles laid down in the National Health Act are the pursuit of greater equity, access to services, quality, comprehensiveness, effectiveness, efficiency, local accountability, community participation and sustainability, and reduced fragmentation through a developmental and intersectoral approach.

6. Working together for the community

a. In order to implement this in South Africa in 2005, officials in all three spheres of government in the health and other sectors will work closely together to provide seamless services in each health district. This is often referred to as Functional Integration. Services will include municipal health services (MHS), other health promotion, home based care, personal PHC and district hospital services. Officials will also work closely with traditional and other private providers, NGOs and Faith Based organizations to promote better health and health services. The District Health Council will play a major role in promoting cooperative governance and functional integration, encouraging all concerned to work together for the benefit of the community.

b. The main implications for the major services are listed below.

7. Municipal Health Services

a. Delivered equitably throughout the district b. Included in the district health plan

c. Coordinated and funded by the district or metropolitan municipality

d. Monitored and supported by the District Health Council

e. Staff employed and managed by the district or metropolitan municipality or, where provision of services has been delegated, by the local municipality.

8. Personal PHC services

a. Delivered equitably throughout the district at arid from community health centers, clinics, mobile clinics and outreach services, with gateway clinics to minimize use of hospitals for PHC services

b. Included in the district health plan

c. Coordinated by the provincial health department it and with formal Service Level Agreements (SLAs) where services are delegated

d. Funded on an equitable basis by the provincial health department, possibly with supplementary funding from a municipality that wishes to have additional services in their area

e. Monitored and supported by the District Health Council

f. All government officials providing personal PHC services in public health facilities in a district or sub-district employed by the same authority

g. Staff employed and managed by the provincial health department or, where provision of services has been delegated, by the metropolitan, district or local municipality.

9. District Hospital services

a. Delivered equitably throughout the district with a focus on providing

i. patient care,

ii. consultations for those referred for further investigation or opinion, and

iii. support for all those providing public or private PHC services in the hospital's referral area

b. Included in the district health plan

c. Coordinated, funded equitably and managed by the provincial health department

d. Monitored and supported by the District Health Council

e. Staff employed and managed by the provincial health department

10. District Health Budget and Plans

a. A budget and plans for all health services in the district, linked to the municipal Integrated Development Plans (IDPs) and developed as part of the IDP process

b. The budget and plans produced each year and discussed by the District Health Council before being approved by the MEC and the Executive Mayor respectively

c. The budget and plans include:

i. All municipal health services and all public personal PHC and district hospital services

ii. A human resource plan for these services

iii. Copies of any Service Level Agreements (SLAs)

iv. In time, also a list of all private health services in the area and any plans for significant changes

C: IMPLICATIONS OF NATIONAL HEALTH ACT

Boundaries of health districts and sub-districts

11 There are 53 health districts in South Africa.

a. The Act specifies that the boundaries of health districts will coincide with the boundaries of district and metropolitan municipalities.

b. If the boundaries of these municipalities change, then the boundaries of the health districts will automatically change.

12.The creation of cross boundary municipalities caused several problems, including problems for health services. A political decision has been taken to abolish cross boundary municipalities and political discussions are taking place with a view to changing certain boundaries. Health district boundaries will change in line with any changes to municipal boundaries, and this should simplify health service delivery and management.

13. MECs for Health have the authority to sub-divide health districts into sub-districts.

a. This can only be done with the concurrence of the relevant MEC for Local Government

b. Various criteria are laid down for determining the boundaries of health sub-districts. These criteria include consideration of efficiency and local accountability

c. Details of such sub-divisions must be published in the Gazette.

i. Although most health districts have beer divided de facto into health sub-districts, these boundaries have usually not been gazetted as yet.

d. It is accepted policy that, in non-metropolitan areas, each health sub-district should comprise the total area of ore or more local municipalities.

e. It is also suggested that in metropolitan areas, a health sub-district should comprise the total area of several wards.

District Health Councils

14. All MECs for Health are required, after appropriate consultation, to establish a District Health Council for each health district.

a. In some places, interim structures are in place. These need to be formally constituted as District Health Councils, or Councils need to be established.

15. The composition and functions of these councils are spelled out clearly in sections 31(2) and (3) of the Act.

16. Provincial legislation is required to govern the functioning of these councils. This is spelled out in section 31(5) of the Act

a. No province yet has legislation that deals with all the aspects listed in section 31(5). Some provinces will need completely new legislation while others may be able simply to amend their existing legislation.

District Health Plans

17.The Act requires 'each district and metropolitan health manager" to prepare a district health plan, "within the national budget cycle" and "in accordance with national guidelines issued by the Director General".

18. Most of the requirements for District Health Plans have already been spelt out in section 10 above.

19.A budget for all health services in the district will require the province to have cost-centre budgeting and to aggregate the cost centers by district. Most provinces already do cost-centre budgeting but do not yet publish their budgets per district.

20. District Health Planning Guidelines prepared and pub shed by the National Department of Health in consultation with the provinces have been available for more than two years. A simplified, revised version has been produced and should be printed and distributed early in 2005.

21.These 2005 guidelines must be issued formally by the Director General and should then be used by all districts for their 2005/06 plans.

District Human Resource Plans

22.The Act also requires that "each health district develops and implements a district human resource plan in accordance with national guidelines issued by the Director General."

23. Considerable work was done in 2004 to develop a model for district health human resource (HR) planning. Districts that used this model found it very useful. Considerable work is also being done on a broader human resource plan for health generally.

24.The work on district HR planning must now be taken further and, in conjunction with the broader framework, incorporated into national guidelines for district HR plans for health.

Provision of Municipal Health Services

25. Municipal Health Services (MHS) have been defined in the National Health Act as including a list of environmental health service

a. The Act does not confine municipalities to providing only these services, but these are the minimum services that should be provided.

b. Three environmental health services are specifically excluded from the definition of MHS. These three (port health, malaria control and control of hazardous substances) remain a provincial responsibility.

26.In 2002, half the Environmental Health Practitioners providing MHS were employed by provinces and the other half by municipalities. The intention is to consolidate these services under the district and metropolitan municipalities.

27.The district and metropolitan municipalities are therefore now responsible for ensuring that these MHS services are developed and provided.

a. In metropolitan areas there are mostly good environmental health services, although these need to be expanded to cover government institutions and some previously under-served areas.

b. In most rural areas, very few environmental health services are currently provided. Posts need to be evaluated and created, staff need to be recruited and appointed, and services must be built up.

c. In some non-metropolitan areas there is some environmental health capacity, mostly in the towns, and this can be built upon.

d. However, a whole new approach of "developmental environmental health" has to be adopted. MHS in rural areas must focus first on such things as:

i. Regular testing of local water supplies, whether ground water or piped, and facilitating projects t) improve the quality of water used by local communities;

ii Teaching at schools, meetings and other opportunities, the importance of health and hygiene in relation to water and sanitation;

iii Facilitating, in collaboration with DWAF, the popularization of proper VIP toilets;

iv. Working closely with the Dept of Agriculture and advising both the department and local farmers on the proper and safe use, and dangers, of pesticides; and

v. Working closely with the Departments of Environmental Affairs and Water Affairs on proper waste disposal, including health care waste, arid the reduction of all forms of pollution.

e. These activities will require skills and job descriptions that are much wider than those of traditional "health inspectors" in urban areas.

Provision of Personal PHC Services

28. Most personal PHC services are already provided by provincial staff.

a. This is particularly true in non-metropolitan areas where 92% of funding for non-hospital personal PHC services comes from provincial funds, and many (provincial) hospitals also provide PHC services.

b. There are many municipal clinics in the cities but often they do not provide comprehensive PHC services and non of them offer 24 hour or 7 day services.

c. Even in metropolitan areas, 78% of funding for non-hospital personal PHC services comes from provincial funds.

29. Because Municipal Health Services has been defined quite "narrowly" in the National Health Act, provinces remain responsible for ensuring the provision of comprehensive personal PHC services.

a. The Budget Council has approved additional funds to provinces in the financial years 2005/06 - 2007/08 to enable the provinces to progressively take over the 8% funding for personal PHC currently provided by non-metropolitan municipalities.

30. A province may chose to provide all personal PHC services itself, or it may chose to delegate some of the provision to a municipality.

a. If it chooses to delegate the provision of services, it must enter into a service level agreement with that municipality. Both parties (province and municipality) must sign the agreement and must then provide the resources and services specified in that agreement.

31 Whether the province chooses to provide all personal PHC services in an area itself, or whether it chooses to delegate provision to a municipality, the province remains responsible and must ensure that services are provided cost-effectively.

a. In practice, this means that where a province chooses to delegate provision of personal PHC services to a municipality and will transfer funds for this purpose, the province needs to be satisfied:

i. that these funds will only be used for the agreed purposes

ii. that if the municipality provides higher remuneration packages than the province would provide for equivalent work, then an appropriate portion of those remuneration packages must come from municipal funds.

Funding MHS

32.Municipal Health Services must be funded by district and metropolitan municipalities. Even if a district municipality delegates the provision of MHS to a local municipality that has the capacity to provide services it is the responsibility of the district municipality to provide funding for that

33. Metropolitan municipalities already provide significant environmental health services and so have significant budgets. Even in these cities however, there are important gaps where services have never been provided, such as providing environmental health inspections and services to prisons and other government institutions. Existing budgets will usually not be sufficient to provide all the services needed, but they provide a good base from which to expand services.

34.ln non-metropolitan areas, most provinces provide some environmental health services and those municipalities that inherited established "white municipalities" also have some environmental health capacity and budgets. However, most rural areas have few if any environmental health services and all the existing non-metropolitan services require major expansion and revision to be able to provide equitable services throughout South Africa.

35. Most district municipalities do not have budgets that a-e anywhere near adequate to start providing MHS throughout their district. Provinces and local municipalities can, theoretically, transfer their staff and assets to the district municipalities but in most districts little can happen until the district municipality has a budget to pay these staff, maintain the assets, provide running costs and start to expand services. A few district municipalities have been able to budget to take over existing staff arid services from local municipalities in 2005/06, and in some cases provinces have seconded Environmental Health Practitioners to district municipalities, but these are the exceptions. In most parts of South Africa, progress towards consolidation of MHS is being blocked by a lack of funds.

36. Municipal health services are all about prevention and promotion. They are not expensive to provide but are also not visible until they break down and a disaster strikes as in a cholera outbreak.

37.The total amount, nationally, needed to provide basic MHS in non-metropolitan areas is not large considering the potential benefits. The Department of Health has requested that National Treasury allocates, to the District Municipalities, R220 million in 2005/06. Th 5 amounts to R7 per capita in each district. This should build up to R330 m in 2006/07, R440 million in 2007/08 and stabilize at R550 million per annum in 2008/09.

38.These funds would allow district municipalities to fund in 2005/06 most of the existing environmental staff and services provided by provinces and local municipalities, and to start to develop services in rural areas that have had none.

39. If the funds come in the Adjustment Budget in November 2005, the 420 newly graduating Environmental Health Practitioners who will have to do their community service from January 2006 could all be employed and could make a significant impact. By 2007/08 there could be a massive improvement in service provision and basic MHS could be provided in all areas by 2009.

40. National Treasury will need to advise how best to earmark the funds in the district municipality budgets to ensure that they are spent on the provision or development of MHS. The Department of Health can, through the provinces, monitor what services are provided but is rot in a position to apply any sanctions if the funds are used for other purposes.

41. Certain people have questioned the wisdom of giving responsibility for MHS to district municipalities. While this can be debated it must not be used as an excuse to delay and deny services to the community. Until such time as parliament decides to amend the Municipal Structures Act and the National Health Act, district municipalities are responsible for the provision of MHS. They must therefore be given the financial resources to fulfill their legal mandate. The funds required are a very small investment that could save many lives.

Funding of personal PHC services

42. Immediate problems with the funding of personal PHC; services in non-metropolitan areas should be resolved with the additional allocations to provinces in 2005/06 through 2006/07 and 2007/08 to enable them progressively to take over the funding currently provided by non-metro municipalities for such services.

43.These additional allocations to the provinces have taken into account the levels of expenditure by non-metropolitan municipaliti35 on personal PHC services in each province.

44. A long term solution to funding personal PHC services in metropolitan areas still needs to be agreed upon. A final resolution will require a political decision.

45. In the medium to long term it is clear that provinces will need to fund personal PHC services on an equitable basis throughout the province. This equitable funding will be a per capita allocation based either on the total population or (if credible data is available) on the uninsured population in that health district.

46. Since 1994, reasonable progress has been made in reducing inter-provincial inequities in funding for health care. The challenge now is to reduce the great inequities in allocations between districts, particularly the allocations for PHC services.

47.At the same time, it is clear that total funding for PHC services in South Africa is not sufficient to provide the comprehensive PHC package in all areas. Research conducted in 2004 has quantified the funding gap but this needs to be linked to the human resource gap before comprehensive proposals can be put forward to fill these gaps.

ACTIONS REQUIRED IN 2005

48.Boundaries of health districts and sub-districts

a. Provincial Health Departments should prepare notices for approval by their MECs for Health and Local Government defining the boundaries of health sub-districts.

b. Once approved, these notices should be published in the gazette

c. Note must be taken of any proposals to change the boundaries of municipalities &/or provinces. Health service boundaries must be changed if necessary if parliament adopts any proposed changes.

49. District Health Councils

a. Provinces must prepare and enact legislation (or amend existing legislation) to provide for the proper functioning of District Health Councils

b. Pending the enactment of the relevant legislation, the MEC for Health should consult appropriately and appoint interim District Health Councils which can then be confirmed in office once the legislation is in place.

c. The interim councils should immediately take on the functions of reviewing budgets and monitoring health services in their districts, and supporting managers in their efforts to improve services.

50. District Health Plans

a. The Department of Health has finalized the amended, simplified guidelines for preparing district health plans, and the Director General has issued them.

b. Provinces must instruct and support each health district manager to prepare a district health plan for 2005/06.

c. These plans must then be tabled and discussed first with the relevant (interim) District Health Council.

51.District human resource plans

a. The Department of Health must finalize and approve the District HR Planning tool, ensuring that it is consistent with the broader HR for Health planning framework

b. Provincial and district managers must be trained to use the tool, building on the training already given for the 13 ISRDP nodes.

c. District management teams must then be encouraged to use the tool to prepare an HR plan for their district.

52. Funding for MHS in non-metropolitan areas

a. Health departments and their political principal' in all three spheres of government must be encouraged to lobby hard for R220 million to be made available on a per capita basis for MHS in non-metro areas in 2005/06, rising to R550 million 2008/09. Efforts should still be made to have the initial R220 million included in the adjustment budget in Nov 2005.

b. This will enable almost all districts outside the W Cape to take over the funding of existing provincial and local municipal services now defined as MHS, and to consolidate and start expanding them. In W Cape which has more services in the non-metro areas than other provinces, district municipalities could take over the funding responsibilities over a period of 3 years.

c. Each district municipality could be required, be<ore the start of their financial year, to table clear plans to consolidate, develop and run MHS. In districts such as OR Tambo with large populations (and therefore relatively large allocations) and almost no existing services, a significant portion of the funds in the first three years could be spent on training as Environmental Health Practitioners, local people who are then prepared and obliged to work, after qualifying, for at least three years in that district.

d. Transfer of existing staff and assets, particularly from local to district municipalities, does not need to happen precipitously and can be a well planned and negotiated process. In some districts this process is well under way but it cannot be completed until funding for district municipalities to provide the services; has been secured.

53. Funding for personal PHC in non-metro areas

a. The funds identified by National Treasury and transferred to the provinces must be clearly identified as being for PHC services.

54. Rationalize personal PHC staff and services in non-metro areas

a. Provinces must work with municipalities to ensure the most rational use of all staff to provide the best and most equitable PHC services that are possible with available resources.

b. Duplication and fragmentation of services must be eliminated.

55. Funding and provision of personal PHC services in metro areas

a. The issues must be presented clearly to the Ministers of Health and of Provincial and Local Government and to their MECs.

b. It is suggested that a firm proposal then be discussed with the Minister of Finance and other cabinet colleagues, and with the Executive Mayors of the Metropolitan Councils.

c. Once a firm political decision has been taken, officials can then develop appropriate strategies to implement it. f no other decision is taken, then provinces will have to plan to become the sole funders of personal PHC services in the metropolitan areas.